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Laparoscopic Sleeve Gastrectomy: A Radiological Guide To Common Postsurgical Failure
Laparoscopic Sleeve Gastrectomy: A Radiological Guide To Common Postsurgical Failure
Laparoscopic Sleeve Gastrectomy: A Radiological Guide To Common Postsurgical Failure
www.carjonline.org
Abstract
Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because
of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical
technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy.
Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate
interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications.
Resume
La gastrectomie longitudinale par laparoscopie figure parmi les interventions bariatriques les plus courantes a l’echelle mondiale. Depuis
peu, elle gagne en popularite, car elle entra^ıne un faible taux de complications, une resolution satisfaisante des comorbidites et une perte de
poids importante. Le present article traite de la technique chirurgicale, des aspects d’imagerie postchirurgicaux attendus et des resultats
d’imagerie associes aux complications courantes suivant la gastrectomie longitudinale par laparoscopie. La comprehension de cette technique
chirurgicale et des caracteristiques anatomiques normales suivant l’intervention permet une interpretation juste des resultats d’imagerie dans
les cas de perte de poids insuffisante, de reprise de poids et de complications postchirurgicales.
Crown Copyright Ó 2017 Published by Elsevier Inc. on behalf of Canadian Association of Radiologists. All rights reserved.
Obesity continues to be a major public health problem in other bariatric procedures and is currently becoming one of
the United States, with more than one-third of adults the most common bariatric procedures worldwide. In com-
considered obese in 2009-2010, as defined by a body mass parison with other bariatric surgeries such as the laparoscopic
index (BMI) >30 kg/m2 [1e3]. Bariatric surgery procedures Roux-en-Y gastric bypass (LRYGB), LSG is a shorter and
are indicated for patients with a BMI >40 kg/m2 without more technically straightforward procedure that leads to fewer
coexisting medical problems and for whom bariatric surgery changes to the body’s normal anatomy and physiology. It has
would not be associated with excessive risk should they be recently increased in popularity because of proven efficacy in
eligible for a bariatric procedure [4]. Patients with a BMI achieving considerable weight loss and comorbidities resolu-
>35 kg/m2 and 1 or more severe obesity-related comorbid- tion without increasing the risk of complications [6,7].
ities may also be offered a bariatric procedure [4,5]. Sleeve gastrectomy was originally performed by Hess [8]
Among different surgical options, laparoscopic sleeve and Marceau [9] in 1998 as the first part of the duodenal
gastrectomy (LSG) has demonstrated benefits comparable to switch operation. In high-risk and super-obese patients (BMI
>50 kg/m2), the gastric sleeve part of the duodenal switch
operation was often performed alone in an attempt to reduce
* Address for correspondence: Fabio Garofalo, MD, Division de Chirurgie
Bariatrique, H^
opital du Sacre-Coeur de Montreal, Universite de Montreal,
morbidity and mortality, and to facilitate the laparoscopic
5400 boul. Gouin ouest, Montreal, Quebec H4J 1C5, Canada. approach [10]. In the past 15 years, LSG has increasingly been
E-mail address: garofalofabio@inwind.it (F. Garofalo). used as a stand-alone primary bariatric procedure and has
0846-5371/$ - see front matter Crown Copyright Ó 2017 Published by Elsevier Inc. on behalf of Canadian Association of Radiologists. All rights reserved.
https://doi.org/10.1016/j.carj.2017.10.004
2 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13
Figure 2. A 45-year old woman who underwent laparoscopic sleeve gastrectomy. (A, B) Sequential computed tomography images show the sleeve gastrectomy
staple line (arrows) with orally administrated iodinated contrast inside the stomach. (C, D) Anteroposterior fluoroscopic images of the same patient post laparoscopic
sleeve gastrectomy. No angulation is demonstrated at the level of the incisura angularis (arrows). The patient presented no postoperative complications.
regain. Water-soluble contrast is usually preferred to barium CT without oral or intravenous iodinated contrast immediately
when there is concern for perforation. In patients with risk of followed by an abdominal CT with oral and intravenous
aspiration, iso-osmolar, low-osmolar, or barium contrast may contrast is the routine protocol at our institution whenever a
be used. If a leak is highly suspected clinically but undetected leak is suspected. Administration of intravenous iodinated
with water-soluble contrast, barium administration may be contrast and image acquisition in portovenous phase (70-
attempted. Fluoroscopic spot images are initially obtained second delay after the start of intravenous [IV] contrast ma-
before contrast ingestion followed by fluoroscopic monitoring terial injection) may aid in the detection of complications such
in the upright or semiupright position while the patient takes as abscesses (2 cm3/kg, maximum 120 mL). The use of oral
sips of contrast. Cine video clips are usually acquired during iodinated contrast ingested immediately before the contrast
sequential swallows to evaluate for leaks [26]. Frontal, enhanced scan can also be very helpful in demonstrating a site
shallow oblique and lateral projections are obtained. This is of leak or fistula formation (diluted mixture of 20-25 cm3 of
complemented by the reverse Trendelenburg position, which water-soluble contrast in 180-225 cm3 of water). The initial
can reveal a leak at the upper part of the stomach not visible noncontrast enhanced scan is useful in ensuring the absence of
on the other projections due to rapid passage of contrast in this pre-existing hyperdense material in the surgical bed, such as
region [27]. Final images are usually obtained after the study hyperdense clot or blood or iodinated contrast from a prior CT
to evaluate for delayed extravasation of contrast and leak [26]. examination. When reviewing CT images performed with oral
Abdominal CT scan can also demonstrate leaks and stenosis or IV contrast, the brightness and the contrast of the image
in addition to providing greater detail about extragastric should be properly set by respectively adjusting the window
findings and complications, including the presence of intra- width (W) and the window level (L). Failing to do so may lead
abdominal hematoma, abscess, and incisional hernia. The to false negatives and false positives. For instance, a high
CT parameters used are identical to the parameters used in the concentration of iodinated material in the postoperative
nonbariatric population, although higher kVp or mA may be stomach may result in streak artifact in the surgical bed,
required to achieve diagnostic image quality. At our centre obscuring a small extraluminal air locule (false negative) or
thin-section images are initially acquired in an axial plane simulating contrast extravasation (false positive). There are no
(1.25-mm thickness) and reconstructed in axial, coronal, and widely accepted display window settings; however, in our
sagittal planes with a 2.5-mm thickness. An initial abdominal experience, review of images for leaks are best performed
4 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13
Figure 3. A 46-year old woman presented with weight regain 18 months after sleeve gastrectomy. (A, B) Sequential anteroposterior fluoroscopy images show
dilatation due to incompletely resected fundus (arrows). The patient subsequently underwent conversion to laparoscopic Roux-en-Y gastric bypass.
using a wide window width (400-2000 HU range) and a Insufficient Weight Loss or Weight Regain
window level set between 40-400 HU. Finally, radiographs are
of limited value but can be useful to detect free peritoneal air Patients appear to be subject to weight regain starting
[28] or to confirm position of various drains or stents. 3 years after their LSG. A systematic review published
A normal UGI examination shows a regular sleeve and the recently by Parikh et al [6], showed 29.9% of weight regain or
staple line may or may not be visible [27]. Passage of oral insufficient weight loss of the LSG patients after 3 years.
contrast should be prompt, although in the very early post- Several factors may be responsible for insufficient weight loss
operative phase, delayed passage of contrast material can be or weight regain. These factors include preoperative super
observed, presumably due to secondary oedema of the pylorus obesity, preoperative metabolic syndrome, and changing di-
and residual stomach. The sleeve can have a filiform pattern, etary habits to high-caloric meals. Furthermore, loss of patient
presumably due to spasm, or a more relaxed appearance [27]. follow-up and inadequate counseling may also play an
As gastric transection begins 4-6 cm proximal to the pylorus, important role in failure.
the pylorus can sometimes appear wider than the sleeve [27]. Anatomic changes of the sleeve can be also a cause of
Normal postoperative CT shows a sleeve with a staple line failure. Radiological interpretation of these modifications
along the transection site with no contrast material leak or
collection in the vicinity of the staple line [27].
can play a vital role in the shared decision-making process. Surgical Complications
Indeed, failure may be due to dilatation of the sleeve gas-
trectomy. Dilation can occur when the upper posterior gastric The increasing popularity of LSG is also partly due to major
pouch is incompletely dissected during the initial procedure advantages that we do not find in other bariatric procedures,
(Figure 3). This may occur as a result of inexperience early such as LRYGB and laparoscopic adjustable gastric banding.
Figure 7. A 42-year-old woman who presented with severe dysphagia to solids and liquids 1 year after sleeve gastrectomy. (A) Axial oblique computed
tomography image shows sharp angulation and severe narrowing at the level of the incisura angularis (arrow). (B) There is homogenous dilatation of the
proximal gastric sleeve with presence of heterogenous intragastric material and iodinated contrast. (C) Notice also the sliding hiatal hernia (arrow) potentially
caused (or increased) by the distal obstruction. Endoscopically, there was a severe angulation and twist at the incisura with difficult passage of the endoscope
and presence of solid food proximally. Conversion to laparoscopic Roux-en-Y gastric bypass resolved the symptoms in this patient.
6 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13
Table 2
CT finding of sleeve gastrectomy complications
Oral iodinated Intravenous
Complication Most common location Most common findings on CT contrast iodinated contrast
Staple line leak Upper stomach Contrast material extravasation. Useful Optional
Free air and/or air fluid levels adjacent to site of leakage.
Phlegmon or abscess formation.
Gap in the staple line.
Stenosis Incisura angularis Dilatation of proximal stomach and esophagus. Useful Optional
Narrowing of the lumen of the stomach.
Persistent column of contrast proximal to the stenosis.
Sharp angulation at the level of the incisura angularis.
Hematoma Left upper abdomen Perigastric collection with high-density internal contents indicating blood Optional Useful
contents and/or internal hematocrit level.
Possible blush of intravenous contrast material, if active bleeding.
Spleen infarction Upper pole Wedge shaped hypodensity in the spleen. Optional Useful
GERD Gastroesophageal Esophageal reflux of oral contrast material. Useful Not needed
junction Presence of a hiatal hernia.
Distended/patulous esophagus.
Neofundus.
CT ¼ computed tomography; GERD ¼ gastroesophageal reflux disease.
Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13 7
Figure 11. A 44-year-old woman presented with nausea, vomiting, and inter-
Figure 9. A 62-year-old woman with leak at the gastroesophageal junction. mittent abdominal pain without fever 35 days after revisional sleeve gastrectomy.
Fluoroscopic image shows small amount of extravasated contrast at the This patient had laparoscopic sleeve gastrectomy after insufficient weight lost
gastroesophageal junction (arrowhead) and iodinated contrast material postegastric plication. Axial image of a computed tomography scan following
opacifying the surgical drain (arrows). The patient was initially treated by administration of oral iodinated contrast material shows a small amount of
primary laparoscopic suture. The patient presented with recurrence of the contrast extravasation and free air (arrows) indicating a microleak at the
leak and final treatment was achieved by endoscopic stenting (not shown). gastroesophageal junction. Treatment was achieved by endoluminal stenting.
8 F. Garofalo et al. / Canadian Association of Radiologists Journal xx (2018) 1e13
been until recently the best option in the treatment of sleeve A chronic fistula after LSG is a challenging problem. If a
leaks. They are, however, prone to migration given their fistula persists for more than 3 months despite adequate
shorter length (up to 155 mm) and are harder to remove due to drainage, endoluminal therapy, and nutritional support, reop-
the ingrowth occurring at both ends of the stent. More recently, eration may be the only solution. Several surgical options have
fully covered Megastents (Taewoong Medical Industries) up to been reported including the creation of a fistulojejunostomy
230 mm in length and with a large diameter (up to 28 mm) connecting a jejunal Roux limb to the fistula (Figure 14) and
appear to be more resistant to migration. They are also easy to total gastrectomy with esophagojejunostomy [24,51]. A
remove given the full silicone covering. Finally, longer Meg- chronic leak can also progress into gastrocolic fistula, espe-
astents allow for a complete stenting of the gastric sleeve past cially when initial control of the leak is not achieved. In the
the incisura angularis, therefore reducing proximal over- medical literature, few case reports have been published
pressure and allowing for a better healing of the tract or fistula documenting the treatment of a gastrocolic fistula post-LGS
(Figure 12). [56,57]. Laparoscopic resection of the fistula tract can be a
Recently, treatment with endoscopically inserted double valid option in these rare cases (Figure 15).
pigtail catheters has been proposed in the European literature
[55]. The pigtail is placed across the fistula between the Abnormal Angulation or Stenosis
lumen of the esophagus and the cavity of the abscess
(Figure 13). This is conceptually similar to the endoscopic Stenosis or obstruction of stomach due to abnormal
transgastric drainage of pancreatic pseudocysts. The pigtail angulation following sleeve gastrectomy has been
allows for internal drainage of the abscess. It is usually increasingly recognized with a reported incidence ranging
endoscopically removed after 3-6 weeks of drainage. between 0.1%-3.9% [38e41]. The most common site of
Figure 12. A 62-year-old woman with a leak at the gastroesophageal junction, 7 days after laparoscopic sleeve gastrectomy. Healing of the leak was initially
attempted via placement of a Wallstent (Boston Scientific, Galway, Ireland) for 4 weeks. (A, B) Axial images and (C) coronal image of a computed tomography
scan following administration of oral (and intravenous) contrast showing the Wallstent (155 mm length, 23 mm diameter) in position across the gastro-
esophageal junction. There is persistent tract and leakage (A, arrow) of contrast material into the collection (B, arrow) in the left upper quadrant. While the
proximal part of the stent covers the site of leak (A, arrowhead), the distal end of the stent (C, arrowhead) is not able to overcome the incisura angularis (C,
arrows). Despite the presence of a Wallstent for 4 weeks, leakage persisted. Complete healing of the leak was achieved by placement of a Megastent (230 mm
length, 28 mm diameter; Taewoong Medical Industries, Gimpo, South Korea) for another 3 weeks. (D) Coronal oblique image of a computed tomography scan
showing the full extent of the Megastent. Not only does the Megastent cover the leak site at the gastroesophageal junction but it also overcomes the incisura
angularis (D, arrow), reducing proximal overpressure, hence promoting healing of the leak.
Laparoscopic sleeve gastrectomy / Canadian Association of Radiologists Journal xx (2018) 1e13 9
Figure 13. A 65-year-old patient presented with a leak at the level of the gastroesophageal junction, 2 days after laparoscopic sleeve gastrectomy. Initial control
of the leak despite Megastent (Taewoong Medical Industries, Gimpo, South Korea) placement was incomplete. Final treatment was achieved by endoscopic
insertion of a double pigtail through the stent allowing internal drainage of the abscess cavity into the esophageal lumen. (A) Scout image showing the
Megastent (A, arrow) and the double pigtail (A, arrowhead). (B) Axial image of a computed tomography scan with intravenous and oral contrast in bone
window (width 2500, length 480) showing the position of the distal loop of the double pigtail in the residual air-containing cavity (B, arrow). (C) Coronal
oblique maximum intensity projection image (10 mm) and (D) axial oblique maximum intensity projection image (20 mm) in the bone window (width 2500,
length 480) showing contrast within the Megastent (C and D, asterisks) and the double pigtail with its distal loop positioned within the residual abdominal
cavity/collection (C, arrowhead) and its proximal loop kept inside the esophageal lumen (D, arrow).
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